Iv moderate sedation
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Transcript

  • 1. IV Moderate Sedation
  • 2. DefinitionI.V. moderate sedation should producean altered sensory condition in whichthe patient exhibits an altered(depressed) level of consciousnesswhile maintaining the ability toindependently and continuouslymaintain a patent airway and respondappropriately to verbal stimuli.
  • 3. Protective ReflexesLoss of reflexes, including theinability to maintain a patent airwayand/or purposeful response tophysical and/or verbal stimulation asa result of a systemicallyadministered drug.
  • 4. LocationOperating RoomPACUEndoscopyOutpatient CenterCritical Care Unit (ICU)Emergency Department
  • 5. ScopeAll moderate sedation will be orderedand directly supervised by thephysician performing the procedure.Administration and/or monitoring ofmonitored sedation may be performedby a qualified physician privilegedor a registered nurse trained inadministering or monitoring conscioussedation.
  • 6. ScopeA physician may waive NPO guidelinesunder any emergency conditions, whichwill be noted in the medical recordPatients with severe systemic diseasepresent on the day a procedure undermonitored sedation is scheduled mayrequire a sub-specialty consultationand/or anesthesia provider
  • 7. ScopePatients with severe systemic diseasepresent on the day a procedure undermonitored sedation is scheduled mayrequire a sub-specialty consultationand/or anesthesia provider
  • 8. ScopeAny Patient Receiving Propofol orKetaminePatients under 60 years of age whoreceive intravenously >5mg of Versedor >20mg of Valium.Patients 60 years of age and olderwho receive intravenously >2mg ofVersed or >10mg of Valium
  • 9. ScopePatients receiving any combination ofIV narcotic and Versed or Valium.
  • 10. Pediatric Patients Demerol combined with Phenergan orThorazine. Chloral Hydrate PO Fentanyl PO Versed Rectal Brevital
  • 11. Physician ResponsibilitiesProviding the level of monitoringspecified in these guidelines and tomanage complications.The practitioner should be trained inand capable of providing basic lifesupport (ACLS Recommended)
  • 12. Physician ResponsibilitiesBeing present when medications formoderate sedation are administered.Be within immediate reach andavailable on the hospital premises ifproblems or emergencies arise.
  • 13. Physician ResponsibilitiesAuthorizing the administration of thesedation within the recommendedsedation dosage guidelines.Writing a post-procedure note anddischarge orders.Determining that the patient is anappropriate candidate for thesedative agent to be administered.
  • 14. Pre-Procedure EvaluationPatient’s ageChief complaintCurrent medicationsHistory of medication allergies/reactionsOverall physical status
  • 15. Pre-Procedure EvaluationConcurrent medical problemsHistory of substance abuseVerification of patient compliancewith pre-procedure instructions(Informed Consent for the procedureto be performed)
  • 16. Pre-Procedure EvaluationDiscussion of risks, benefits, andalternativesPhysical examination pertinent to thehistory and procedure to be performed
  • 17. ASA ClassificationClass I normal healthy patientClass II patient with mild systemicdiseaseClass III patient with severesystemic disease with functionallimitationsClass IV patient with severesystemic disease that is constantthreat to life
  • 18. RN ResponsibilitiesAdequate transportation andpostoperative care arrangements madefor discharge.History and Physical present in themedical record.Proper consent(s) signed for theprocedure.
  • 19. RN ResponsibilitiesVerify the patient has been NPOVerify allergies.Verify pregnancy statusAssure recent lab results areavailable in the medical record.Document baseline vital signs
  • 20. RN ResponsibilitiesDocument baseline SaO2 (room air ifO2 therapy not being implemented)Complete a pre-procedure assessment.Assure a patent IV accessVerify equipment is functioningproperly prior to use.
  • 21. RN ResponsiblitiesDocument emotional state.Document level of consciousness.Document skin signsVerify perceptions regardingprocedures and level of sedation.
  • 22. Goals And ObectivesAllay patient fears and anxietyregarding the planned procedure(s)Alteration in moodMaintenance of consciousnessCooperationElevation in pain threshold
  • 23. Goals And Objectives Minimum variation of vital signs Amnesia Rapid, safe return to ambulation
  • 24. RN ResponsibilitiesAdminister medications as directed bythe privileged physician present.Notify physician of any significantchange in the patient’s physiologicstatus.
  • 25. RN ResponsibilitiesThe nurse managing the sedation ofthe patient shall have no otherresponsibilities that would interferewith continuing monitoring care,physical care, and emotional support.
  • 26. EquipmentOxygen delivery in placePulse oximetry equipment in placeAn I.V. access line established andpatency maintainedCardiac and blood pressure monitoringin place
  • 27. Equipment (Present & Available) There shall be an emergency code cart immediately available with emergency resuscitative drugs and defibrillator. Oxygen and appropriate O2 delivery systems Suction and appropriate suction equipment
  • 28. Equipment (Present & Available) Bag, valve, mask breathing devices Oral/nasopharyngeal airways and endotracheal tubes of various sizes Sphygmomanometer and/or non-invasive blood pressure monitor EKG monitor
  • 29. Equipment (Present & Available) Pulse oximeter Pharmacologic antagonists: Narcan and Romazicon (Flumazenil)
  • 30. MonitoringRespiratory rateO2 saturationBlood pressureCardiac rate and rhythmLevel of consciousness (Aldrettescore)Skin condition
  • 31. Aldrette Score ActivityAble to move 4 extremities……………2Able to move 2 extremities………….1Able to move 0 extremities……………0
  • 32. Aldrette Score RespirationDeeply breathes, coughs freely………2Dyspnea or limited breathing…………1Apneic………………………………………………….......0
  • 33. Aldrette Score CirculationSystolic BP +/- 20 mmHg pre-procedurelevel………2Systolic BP +/- 20 mmHg–50mmH Pre-procedure level……………………………1Systolic BP +/- 50 mmHg pre-procedurelevel………… 0
  • 34. Aldrette Score ConsciousnessFully awake……………………………………………. 2Arises on calling…………………………………1Unresponsive…………………………………………… 0
  • 35. Aldrette Score ColorPink………………………………………………...........2Pale, dusky, blotchy, jaundiced……1Cyanotic……………………………………………........0
  • 36. Continuous MonitoringDesired therapeutic effectsAdverse effects with appropriateintervention/prevention of theseadverse effects.Early detection of non-preventableadverse effectsPatient’s response
  • 37. Continuous MonitoringAssess and document vital signs at aminimum of every 5 minutes or morefrequently during drug administrationand during the procedure.
  • 38. Post Procedure MonitoringVital signs (BP, EKG/HR, RR)Oxygenation (SaO2)Level of consciousness and Return topre-sedation status
  • 39. Post Procedure MonitoringAssess and document vital signs at aminimum of every 15 minutes x 2, thenevery 30 minutes x 2, then every hourx 2, then every 2 hours x 4Continuous SaO2 monitoring for aminimum of 30 minutes, recheck anddocument SaO2 immediately prior todischarge
  • 40. Transfer RequirementsO2 saturation maintained at pre-procedure level or >92%, with orwithout oxygen, at a respiratory rateof 12 or greaterIntact protective reflexes, muscularstrengthAble to cough and/or demonstrate gagreflexes
  • 41. Transfer RequirementsRespond to verbal commandsMaintain patent airway, independentlyand continuouslyAbsence of restlessness, cyanosis,pallor, flushing, diaphoresis, orpalpitationNo evidence of bleeding
  • 42. Discharge CriteriaConsciousness: Awake and respondingappropriately, > 1 hour post reversaldrugCirculation: BP within acceptablepre-operative levelsOxygen saturation > or = to 95% inthe unstimulated patient on room airor equal to pre-procedure saturation.
  • 43. Discharge CriteriaFluid intake: Taking P.O. fluidswithout nauseaActivity level: Ambulate withminimal assistance with stable BPBody functions: Patients who haveundergone regional anesthesia,urological, gynecological, or herniaprocedures must be able to void
  • 44. Discharge CriteriaStable wound sitePain within tolerable limits with/without P.O. medicationAdequate neurovascular status ofoperative extremity (if applicable)Modified Aldrette score of 8 orgreater
  • 45. Dishcarge CriteriaIf the patient does not meet theabove criteria, a discharge ordermust be obtained from the surgeonand/or consulting Anesthesiologist/CRNA.If the above criteria are not metafter four hours, the attendingphysician should be notified.
  • 46. DocumentationThe Local/ Moderate SedationOperative Record will be utilized forall patients receiving conscioussedation in every patient care area.
  • 47. DocumentationThe Emergency and Critical CareDepartments may utilize only thegraph portion of the Local/ MonitoredSedation Operative Record if allother pertinent information isdocumented on the EmergencyDepartment Clinical Record or theCritical Care Flow Sheets.
  • 48. DocumentationShall reflect evidence of continuousassessment, diagnosis, outcome,identification, planning,implementation, and evaluation ofcare
  • 49. DocumentationPatient care management immediatelybefore administration of monitoredsedation drugs, during the sedationphase, and immediately post-procedure(recovery).Dosage, route, time and effects ofdrugs usedType and amounts of fluids
  • 50. DocumentationPhysiologic data from continuousmonitoring at a minimum of 5 minuteintervals and with any significantevent during the procedure.Level of consciousness
  • 51. DocumentationSignificant adverse patient eventswith corrective action taken andeffects of action taken.Condition at transfer in the eventthe patient is transferred to anotherpatient care area
  • 52. Reportable ConditionsDeep sedation (unintended)Unexpected Phase I recoveryAssisted Ventilation is required.There is an unanticipated hospitaladmission and/or an increased levelof care required
  • 53. Reportable ConditionsAny case in which the SaO2 remains <90% or 3% less than baseline for morethan three (3) minutes after O2administration.Any case in which SaO2 is 80% or lessat any time.
  • 54. Reportable ConditionsAny case in which there ishemodynamic instability (defined as a20% change from baseline bloodpressure or heart rate) requiringmedications and/or medicalinterventions.A reversal agent is administered
  • 55. Reportable ConditionsLack of adherence to hospital policyon Moderate Sedation.ET intubationCardiac arrestAdverse medication reaction
  • 56. Reportable ConditionsProlonged recovery from sedation (> 2hours post procedure)Patient, family, or staff complaintregarding quality of sedation/analgesia.Unexpected need for Anesthesiologist/CRNA
  • 57. QualificationsPhysicians intending to use agentsfor the purpose of monitored sedationmust be specifically privileged.Anesthesiologists, CRNAs, BoardCertified Physicians in Critical Care(Adult & Pediatric) and BoardCertified Physicians in EmergencyMedicine will be granted privileges.
  • 58. RN QualificationsRNs who monitor patients receivingI.V. moderate sedation will havecompleted competencies in ModerateSedation.The nurse monitoring the patient careshall be aware of the desirable andundesirable effects of I.V. moderatesedation.
  • 59. RN QualificationsThe nurse shall have the knowledgeand skills to intervene in the eventof a complication.
  • 60. Desirable EffectsIntact protective reflexesRelaxationCooperationDiminished verbal communicationEasy arousal from sedation
  • 61. Undesirable EffectsNystagmusUnarousable sleep/sedationHypotensionAgitationCombativenessHypoventilation
  • 62. Undesirable EffectsRespiratory DepressionAirway obstructionApnea
  • 63. RN QualificationsThe nurse monitoring the patientshall have a working knowledge ofresuscitation equipment and thefunction and use of monitoringequipment and should be able tointerpret the data obtained.
  • 64. RN QualificationsThe nurse shall demonstrate skills inbasic life support and have CurrentBLS recognition. ACLS isrecommended.
  • 65. RN QualificationsAnatomy and physiologyPharmacology of drugs usedCardiac arrhythmia interpretation
  • 66. RN QualificationsComplications related to the use ofI.V. conscious sedationPrinciples of oxygen delivery andrespiratory physiologyDemonstrate knowledge of properdosages, administration, adversereactions, and interventions foradverse reactions and overdoses.
  • 67. RN QualificationsAssess total patient carerequirements or parameters, includingbut not limited to respiratory rate,oxygen saturation, blood pressure,cardiac rate and rhythm, and level ofconsciousness.
  • 68. BenzodiazepinesMost common are midazolam (Versed®),diazepam (Valium®), and lorazepam(Ativan®)Most often administered for sedationand amnesia or as adjuncts to generalanesthesia (usually a pre op med)
  • 69. BenzodiazepinesCNS – amnestic, anticonvulsant,hypnotic, muscle relaxant, andsedative effects in a dose dependentmanner.Cardiovascular – mild systemicvasodilatation and reduction incardiac output (more pronounced withadded narcotic)
  • 70. BenzodiazepinesRespiratory – mild decrease in RR andtidal volume (more pronounced withadded narcotic)Reversal of benzodiazepines isaccomplished with flumazenil ifneeded (antagonist)May cause venous irritation
  • 71. NarcoticsFentanyl and sufentanil are the majornarcotics used intraoperatively.Morphine, demerol, and fentanyl arethe major narcotics usedpostoperatively.In high doses, narcotics areoccasionally employed as the soleanesthetic (e.g. cardiac surgery)
  • 72. NarcoticsPrimary effect is analgesia, andtherefore they are used primarily tosupplement other anesthetics duringinduction or maintenance of generalanesthesia.
  • 73. Narcotics CNSSedation and analgesiaEuphoria also common.In large doses amnesia and loss ofconsciousness.Demerol can cause Seizures
  • 74. Narcotics CardiovascularSVR moderately reducedDemerol a direct myocardialdepressant.Enhance myocardial depressant effectsof other anestheticsBradycardia in a dose-dependentmanner (eg fentanyl)Morphine and Demerol can causehistamine release
  • 75. NarcoticsRespiratory depression in a dose-dependent manner.Miosis may be a useful guide in theassessment of narcotic effectMuscle rigidityNausea and vomitingUrinary retention
  • 76. NarcoticsFentanyl Quick onset...goes awayquick (peak effect 5-7 minutes)Morphine peak effect 30 minDemerol peak effect 15 min
  • 77. PropofolUsed for induction and/or maintenanceof general anesthesia.Also used in lower doses for sedation
  • 78. PropofolRapidly induces unconsciousness withrapid recovery due to redistributionof the drug.Decreases in arterial blood pressureand cardiac output in a dose-dependent manner (cardiovasculardepressant).Dose-dependent decrease inrespiratory rate and tidal Volume.